Comparative effectiveness of endovascular treatment modalities for de novo femoropopliteal lesions at long-term follow-up: A network meta-analysis of randomized controlled trials

PURPOSE

To evaluate the best endovascular treatment for de novo femoropopliteal lesions at long-term follow-up through network meta-analysis of randomized controlled trials.

METHODS

Medical databases were searched on September 17, 2023. 17 trials and 7 treatments were selected. Outcomes were primary patency, target lesion revascularization (TLR), major amputation and all-cause mortality at 3 and/or 5 years.

RESULTS

Regarding 3-year primary patency, drug-eluting stents (DES) was the best and better than balloon angioplasty (BA; odds ratio [OR], 4.96; 95% confidence interval [CI], 2.68-9.18), bare metal stents (BMS; OR, 2.81; 95% CI, 1.45-5.46), cryoplasty (OR, 6.75; 95% CI, 2.76-16.50), covered stents (CS; OR, 3.25; 95% CI, 1.19-8.87) and drug-coated balloons (DCB; OR, 2.04; 95% CI, 1.14-3.63). Regarding 5-year primary patency, DES was the best and better than BMS (OR, 2.34; 95% CI, 1.10-4.99). Regarding 3-year TLR, DES was the best and better than BA (OR, 0.24; 95% CI, 0.13-0.44). Regarding 5-year TLR, DES was the best and better than BA (OR, 0.20; 95% CI, 0.09-0.42) and balloon angioplasty with brachytherapy (OR, 0.21; 95% CI, 0.06-0.74). Regarding 3- and 5-year major amputation, DCB was the best. Regarding 3-year mortality, DES was the best and better than CS (OR, 0.09; 95% CI, 0.01-0.67).

CONCLUSIONS

DES was the best treatment regarding 3-year primary patency, TLR and mortality, and DCB was the best regarding major amputation. DES was the best treatment regarding 5-year TLR, and DCB was the best regarding primary patency and major amputation. DES and DCB should be given priority in treating femoropopliteal lesions.

Efficacy and Safety of a New Delivery Assist Catheter with a Flexible, Spindle-shaped Shaft, in Mechanical Thrombectomy

OBJECTIVES

Large-bore aspiration catheters (AC) are used successfully in mechanical thrombectomy (MT). However, tortuous access routes prevent device navigation because of the ledge effect. The AXS Offset™ Delivery Assist Catheter is designed to reduce the ledge effect. The purpose of this study was to evaluate whether the Offset™ affects AC navigation compared with standard inner microcatheters in MT.

MATERIALS AND METHODS

We retrospectively investigated 75 MTs for anterior circulation occlusion between January 2018 and May 2022 at our hospital. All MTs were performed using an AC, and two types of inner microcatheter (Offset™ or 0.021-0.027-inch standard microcatheter) were chosen randomly during AC navigation. The patients' characteristics, MT techniques, angiographic findings, and clinical outcomes were compared between the Offset and standard group (Non-Offset). The puncture to first pass of the lesion (PTFP) time was investigated to compare the characteristics of the inner catheters.

RESULTS

The Offset group comprised 12 patients vs 63 in the Non-Offset group. Although most baseline clinical characteristics and outcomes were similar between the groups, the PTFP time was significantly shorter in the Offset vs Non-Offset group (31 ± 10 vs 46 ± 24 min, respectively; p = 0.032). In the Offset group, all stent retrievers were deployed via the Offset. One artery dissection and eight symptomatic intracranial hemorrhages occurred in the Non-Offset group; no complications occurred in the Offset group.

CONCLUSIONS

The AXS Offset™ delivery assist catheter permitted faster and safer navigation of various ACs to the occlusions compared with standard delivery microcatheters in MT.

Aneurysm Sac Dynamics and its Prognostic Significance Following Fenestrated and Branched Endovascular Aortic Aneurysm Repair

OBJECTIVE

This study aimed to assess aneurysm sac dynamics and its prognostic significance following fenestrated and branched endovascular aneurysm repair (F/BEVAR).

METHODS

Patients undergoing F/BEVAR for degenerative complex aortic aneurysm from 2008 to 2020 at two large vascular centres with two imaging examinations (30 day and one year) were included. Patients were categorised as regression and non-regression, determined by the proportional volume change (> 5%) at one year compared with 30 days. All cause mortality and freedom from graft related events were assessed using Kaplan-Meier methods. Factors associated with non-regression at one year and aneurysm sac volume over time were examined for FEVAR and BEVAR independently using multivariable logistic regression and linear mixed effects modelling.

RESULTS

One hundred and sixty-five patients were included: 122 FEVAR, of whom 34% did not regress at one year imaging (20% stable, 14% expansion); and 43 BEVAR, of whom 53% failed to regress (26% stable, 28% expansion). Following F/BEVAR, after risk adjusted analysis, non-regression was associated with higher risk of all cause mortality within five years (hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.09 - 5.37; p = .032) and higher risk of graft related events within five years (HR 2.44, 95% CI 1.10 - 5.26; p = .029). Following multivariable logistic regression, previous aortic repair (odds ratio [OR] 2.56, 95% CI 1.11 - 5.96; p = .029) and larger baseline aneurysm diameter (OR/mm 1.04, 95% CI 1.00 - 1.09; p = .037) were associated with non-regression at one year, whereas smoking history was inversely associated with non-regression (OR 0.21, 95% CI 0.04 - 0.96; p = .045). Overall following FEVAR, aneurysm sac volume decreased significantly up to two years (baseline vs. two year, 267 [95% CI 250 - 285] cm3vs. 223 [95% CI 197 - 248] cm3), remaining unchanged thereafter. Overall following BEVAR, aneurysm sac volume remained stable over time.

CONCLUSION

Like infrarenal EVAR, non-regression at one year imaging is associated with higher five year all cause mortality and graft related events risks after F/BEVAR. Following FEVAR for juxtarenal aortic aneurysm, aneurysm sacs generally displayed regression (66% at one year), whereas after BEVAR for thoraco-abdominal aortic aneurysm, aneurysm sacs displayed a concerning proportion of growth at one year (28%), potentially suggesting a persistent risk of rupture and consequently requiring intensified surveillance following BEVAR. Future studies will have to elucidate how to improve sac regression following complex EVAR, and whether the high expansion risk after BEVAR is due to advanced disease extent.

Geometric Analysis of the Gore Excluder Conformable Endoprosthesis in the Infrarenal Aortic Neck: One Year Results of the EXCeL Registry

OBJECTIVE

The Gore Excluder Conformable Endoprosthesis (CEXC) is designed to treat challenging infrarenal anatomy because of its active angulation control, repositionability, and enhanced conformability. This study evaluated 30 day and one year position and apposition of the CEXC in the infrarenal neck.

METHODS

Patients treated with the CEXC between 2018 and 2022 with an available 30 day computed tomography angiography (CTA) were selected from four hospitals in a prospective registry. Endograft apposition (shortest apposition length [SAL]) and position (shortest fabric distance [SFD]) were assessed on the 30 day and one year CTAs. Maximum infrarenal aortic curvature was compared between the pre-operative and post-operative CTAs to evaluate conformability of the CEXC.

RESULTS

There were 87 patients with a 30 day CTA, and for 56 of these patients the one year CTA was available. Median (interquartile range [IQR]) pre-operative neck length was 22 mm (IQR 15, 32) and infrarenal angulation was 52° (IQR 31, 72). Median SAL was 21.2 mm (IQR 14.0, 29.3) at 30 days for all included patients. The SAL in 13 patients (15%) was < 10 mm at 30 days, and one patient had a SAL of 0 mm and a type Ia endoleak. There was no significant difference in SAL between patients within and outside instructions for use. The SAL significantly increased by 1.1 mm (IQR -2.3, 4.7; p = .042) at 1 year. The SAL decreased in seven patients (13%), increased in 13 patients (23%), and remained stable in 36 patients (64%). Median SFD was 2.0 mm (IQR 0.5, 3.6) at 30 days, which slightly increased by 0.3 mm (IQR -0.5, 1.8; p = .019) at 1 year. One patient showed migration (SFD increase ≥ 5 mm). Median endograft tilt was 15.8° (IQR 9.7, 21.4). Pre-operative maximum infrarenal curvature was 36 m-1 (IQR 26, 56) and did not significantly change thereafter.

CONCLUSION

In most patients, the CEXC was implanted close to the renal arteries, and sufficient (≥ 10 mm) post-operative apposition was acquired at 30 days, which slightly increased at one year. Post-operative endograft tilt was relatively low, and aortic geometry remained unchanged after implantation of the CEXC, probably due to its high conformability.

Editor's Choice - Radiation Dose Reduction During Contralateral Limb Cannulation Using Fiber Optic RealShape Technology in Endovascular Aneurysm Repair

OBJECTIVE

The increasing number of endovascular procedures has resulted in an increasing radiation burden, particularly for the treatment team. Fiber Optic RealShape (FORS) technology uses laser light instead of fluoroscopy to visualise the endovascular guidewire and catheters. These devices can be used during the navigational part of procedures, such as cannulation of the contralateral limb (CL) in endovascular aneurysm repair (EVAR). The aim of this study was to describe the effect of using FORS on radiation dose during CL cannulation in standard EVAR.

METHODS

This was a non-randomised, retrospective comparison study of prospectively collected, single centre data from FORS guided EVAR compared with a conventional fluoroscopy only guided EVAR cohort. A total of 27 FORS guided cases were matched 1:1 based on sex, age, and body mass index (BMI) with 27 regular (fluoroscopy only) EVARs. This study primarily focused on (1) technical success of FORS and (2) navigation time and radiation dose (cumulative air kerma [CAK], air kerma area product [KAP], and fluoroscopy time [FT]) during cannulation of the CL. In addition, overall procedure time and radiation dose of the complete EVAR procedure were studied.

RESULTS

In 22 (81%) of the 27 FORS guided cases the CL was successfully cannulated using FORS. All radiation dose parameters were significantly lower in the FORS group (CAK, p < .001; KAP, p = .009; and FT, p < .001) for an equal navigation time (p = .95). No significant differences were found when comparing outcomes of the complete procedure.

CONCLUSION

Use of FORS technology significantly reduces radiation doses during cannulation of the CL in standard EVAR.

Safety and efficacy of large-bore uncovered stents for treating malignant superior vena cava syndrome

PURPOSE

To investigate the safety and efficacy of large-bore uncovered stents for treating malignant superior vena cava syndrome.

METHODS

This retrospective study included 115 patients (89 men, 26 women; mean age 63.2 years; range 21-83 years) who underwent endovascular large-bore (≥18 mm in diameter) uncovered stent placement between August 2015 and July 2022. One patient was lost to follow-up. Therefore, 114 patients were available for follow-up.

RESULTS

Stent placement was technically successful in all 115 patients. Minor procedure-related complications occurred in nine (7.8 %) patients. One hundred eight (93.9 %) patients experienced complete or marked symptomatic relief (Kishi score ≤ 2) at a mean of 3 days after procedure. The cumulative stent patency rates were 98.2 %, 95 %, 93.7 %, 91.5 %, 83.5 %, and 83.5 % at 1, 3, 6, 12, 18, and 24 months, respectively. Stent occlusion occurred in ten (8.8 %) of 114 patients at a mean of 215 days (range 1-732 days) due to thrombosis (n = 7) and tumor ingrowth (n = 3). Stent occlusion did not occur in 21 patients who underwent subsequent central venous catheter insertion. The median patient survival time was 159 days (95 % confidence interval 102-216 days). Univariate and multivariate Cox regression analysis revealed adjuvant anticancer treatment (p = 0.001) and tumor response (p < 0.001) as independent predictors of patient survival.

CONCLUSIONS

Endovascular placement of large-bore uncovered stents was a safe and effective treatment for malignant superior vena cava syndrome. Large-bore stent placement can effectively prevent stent occlusion by tumor ingrowth in most cases, and it can provide a sufficient diameter for subsequent insertion of central venous catheters.

Cutting Balloon Angioplasty for Severe In-Stent Restenosis after Carotid Artery Stenting: Long-Term Outcomes and Review of Literature

PURPOSE

Cutting balloon-percutaneous transluminal angioplasty (CB-PTA) is a feasible treatment option for in-stent restenosis (ISR) after carotid artery stenting (CAS). However, the longterm durability and safety of CB-PTA for ISR after CAS have not been well established.

MATERIALS AND METHODS

We retrospectively reviewed medical records of patients with ISR after CAS who had been treated with CB-PTA from 2012 to 2021 in our center. Detailed information of baseline characteristics, periprocedural and long-term outcomes, and follow-up imaging was collected.

RESULTS

During 2012-2021, a total of 301 patients underwent CAS. Of which, CB-PTA was performed on 20 lesions exhibiting severe ISR in 18 patients following CAS. No patient had any history of receiving carotid endarterectomy or radiation therapy. These lesions were located at the cervical segment of the internal carotid artery (n=16), proximal external carotid artery (n=1), and distal common carotid artery (n=1). The median time interval between initial CAS and detection of ISR was 390 days (interquartile range 324-666 days). The follow-up period ranged from 9 months to 9 years with a median value of 21 months. Four patients (22.2%) were symptomatic. The average of stenotic degree before and after the procedure was 79.2% and 34.7%, respectively. Out of the 18 patients receiving CB-PTA, 16 (88.9%) did not require additional stenting, and 16 (88.9%) did not experience recurrent ISR during the follow-up period. Two patients who experienced recurrent ISR were successfully treated with CB-PTA and additional stenting. No periprocedural complication was observed in any case.

CONCLUSION

Regarding favorable periprocedural and long-term outcomes in our single-center experience, CB-PTA was a feasible and safe option for the treatment of severe ISR after CAS.

Imaging follow-up strategy after endovascular treatment of Intracranial aneurysms: A literature review and guideline recommendations

OBJECTIVE

Endovascular coil embolization is the primary treatment modality for intracranial aneurysms. However, its long-term durability remains of concern, with a considerable proportion of cases requiring aneurysm reopening and retreatment. Therefore, establishing optimal follow-up imaging protocols is necessary to ensure a durable occlusion. This study aimed to develop guidelines for follow-up imaging strategies after endovascular treatment of intracranial aneurysms.

METHODS

A committee comprising members of the Korean Neuroendovascular Society and other relevant societies was formed. A literature review and analyses of the major published guidelines were conducted to gather evidence. A panel of 40 experts convened to achieve a consensus on the recommendations using the modified Delphi method.

RESULTS

The panel members reached the following consensus: 1. Schedule the initial follow-up imaging within 3-6 months of treatment. 2. Noninvasive imaging modalities, such as three-dimensional time-of-flight magnetic resonance angiography (MRA) or contrast-enhanced MRA, are alternatives to digital subtraction angiography (DSA) during the first follow-up. 3. Schedule mid-term follow-up imaging at 1, 2, 4, and 6 years after the initial treatment. 4. If noninvasive imaging reveals unstable changes in the treated aneurysms, DSA should be considered. 5. Consider late-term follow-up imaging every 3-5 years for lifelong monitoring of patients with unstable changes or at high risk of recurrence.

CONCLUSIONS

The guidelines aim to provide physicians with the information to make informed decisions and provide patients with high-quality care. However, owing to a lack of specific recommendations and scientific data, these guidelines are based on expert consensus and should be considered in conjunction with individual patient characteristics and circumstances.

Transradial approach for coil embolization of a ruptured intracranial aneurysm during pregnancy to minimize fetal radiation exposure

Endovascular treatment of aneurysmal subarachnoid hemorrhage during pregnancy involves a risk of intraoperative radiation exposure to the fetus. The transradial approach does not require fluoroscopy of the maternal abdominopelvic region, which reduces fetal radiation exposure. We report a case of a female at 21 gestation weeks who developed subarachnoid hemorrhage due to a ruptured right posterior communicating artery aneurysm. The patient underwent balloon-assisted coil embolization via the transradial approach, which achieved aneurysmal obliteration with minimal fetal radiation exposure and without puncture site complications. The patient was free from neurological sequelae. Further, the patient delivered a healthy newborn through an elective cesarean section at 37 gestation weeks without any complications. The transradial approach allows endovascular treatment of ruptured intracranial aneurysms during pregnancy, with minimal risks of fetal radiation exposure.

Feasibility study of Syngo iFlow in predicting hemodynamic improvement post-endovascular procedure in peripheral artery disease

OBJECTIVE

This study endeavors to examine the feasibility of predicting the clinical outcomes of patients suffering from peripheral artery disease (PAD) who undergo endovascular intervention, by employing the Syngo iFlow technology.

METHODS

Retrospectively enrolling 76 patients from December 2021 to May 2023, yielding a total of 77 affected limbs, this study employs clinical outcomes (improvement or otherwise) as the gold standard. Two physicians conducted visual assessments on both DSA and iFlow images to gauge patient improvement and assessed inter-observer consistency for each image modality. The Time to Peak (TTP) of regions of interest (ROI) at the femoral head, knee joint, and ankle joint was measured. Differences in pre- and post-procedure TTP were juxtaposed, and statistically significant parameter cutoff values were identified via ROC analysis. Employing these cutoffs for TTP classification, multivariate logistic regression and the C-statistic were utilized to assess the predictive value of distinct parameters for clinical success.

RESULTS

Endovascular procedure exhibited technical and clinical success rates of 82.58 and 75.32%, respectively. Diagnostic performance of iFlow image visual assessment surpassed that of DSA images. Inter-observer agreement for iFlow and DSA image evaluations was equivalent (κ = 0.48 vs 0.50). Post-classification using cutoff values, multivariate logistic regression demonstrated the statistical significance of ankle joint TTP in post-procedure iFlow images of the endovascular procedure for clinical success evaluation (OR 7.21; 95% CI 1.68, 35.21; P = 0.010), with a C-statistic of 0.612.

CONCLUSION

Syngo iFlow color-encoded imagery holds practical value in assessing the technical success of post-endovascular procedures, offering comprehensive lower limb arterial perfusion visualization. Its quantifiable parameters exhibit promising potential for prognosticating clinical success.

Usefulness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling puerperal bleeding in patients with abnormal placental implantation

BACKGROUND AND AIMS

Abnormalities of placental implantation, which make up the spectrum of placenta accreta, are associated with high maternal morbidity and mortality due to massive bleeding during delivery. Placing aortic occlusion balloons helps control the bleeding, facilitating surgical intervention. A new device, resuscitative endovascular balloon occlusion of the aorta (REBOA), minimizes the risks and complications associated with the placement of traditional aortic balloons and is also efficacious in controlling bleeding. The aim of this study is to evaluate the usefulness, efficacy, and safety of REBOA in puerperal bleeding due to abnormalities of placental implantation.

MATERIAL AND METHODS

Between November 2019 and November 2021, our interventional radiology team placed six REBOA devices in six women scheduled for cesarean section due to placenta accrete.

RESULTS

Mean blood loss during cesarean section after REBOA (3507.5 mL) was similar to the amounts reported for other aortic balloons. The mean number of units of packed red blood cells required for transfusion was 3.5. Using REBOA provided the surgical team with adequate conditions to perform the surgery. There were no complications derived from REBOA, and the mean ICU stay was <2 days.

CONCLUSION

The technical characteristics of the REBOA device make it a safe and useful alternative for controlling massive bleeding in patients with placenta accreta.

Management and Outcome of Intracranial Dural Arteriovenous Fistulas That Have Caused a Hemorrhage in the Posterior Fossa : A Clinical Study

OBJECTIVE

We evaluated the diagnosis, treatment, and long-term results of patients with dural arteriovenous fistula (dAVF), which is a very rare cause of posterior fossa hemorrhage.

METHODS

This study included 15 patients who underwent endovascular, surgical, combined, or Gamma Knife treatments between 2012 and 2020. Demographics and clinical features, angiographic features, treatment modalities, and outcomes were analyzed.

RESULTS

The mean age of the patients was 40±17 years (range, 17-68), and 68% were men (11/15). Seven of the patients (46.6%) were in the age group of 50 years and older. While the mean Glasgow coma scale was 11.5±3.9 (range, 4-15), 46.3% presented with headache and 53.7% had stupor/coma. Four patients (26.6%) had only cerebellar hematoma and headache. All dAVFs had cortical venous drainage. In 11 patients (73.3%), the fistula was located in the tentorium and was the most common localization. Three patients (20%) had transverse and sigmoid sinus localizations, while one patient (6.7%) had dAVF located in the foramen magnum. Eighteen sessions were performed on the patients during endovascular treatment. Sixteen sessions (88.8%) were performed with the transarterial (TA) route, one session (5.5%) with the transvenous (TV) route, and one session (5.5%) with the TA+TV route. Surgery was performed in two patients (14.2%). One patient (7.1%) passed away. While there were nine patients (64.2%) with a Rankin score between 0 and 2, the total closure rate was 69.2% in the first year of control angiograms.

CONCLUSION

In the differential diagnosis of posterior fossa hemorrhages, the differential diagnosis of dAVFs, which is a very rare entity, should be considered, even in the middle and elderly age groups, in patients presenting with good clinical status and pure hematoma. The treatment of such patients can be done safely and effectively in a multidisciplinary manner with a good understanding of pathological vascular anatomy and appropriate endovascular treatment approaches.

Delayed fatal rupture of vertebral artery after treated with flow-diverter in fibromuscular dysplasia patient: A case report and review of the literature

Fibromuscular dysplasia (FMD) is a noninflammatory arterial diseases that affects predominantly women. Multiple studies have demonstrated an increased prevalence of FMD in patients who experience carotid or vertebral artery dissection (VAD). This case report presents a 57-year-old female who presented with a headache and was diagnosed with partially thrombosed giant aneurysm of vertebral artery. This aneurysm was successfully treated with flow-diverter and coil, but new onset rupture of vertebral artery was detected two weeks later, leading to internal trapping. This case report underscores the need for awareness and understanding of treatment of dissection and aneurysm in patient who is suspected FMD.

Cadaveric aortic aneurysm creation: A life-like model for training endovascular repair

The recent decline in RAAA incidence and the fast paced scenario with associated challenges regarding training calls for initiative for a better training environment to maximize learning. This led us to the creation of a pulsatile human cadaveric RAAA model. Fresh frozen cadaver was used to create RAAA with BioTissue in hybrid suite with ability to perform CBCTA for sizing. As a proof of concept, the model was used to perform REVAR with proximal CODA balloon control. The model proved to be feasible and we believe it is a better environment to train and gain adequate proficiency in RAAA management.

Obscured Segments of Ruptured Brain Arteriovenous Malformations: Insights from Their Visualization during Emergency Transarterial Embolization

A ruptured brain arteriovenous malformation (bAVM) presenting with a hematoma may have unseen parts of the shunts in diagnostic angiography in the acute phase, which may lead to innate incomplete evaluation for the whole angioarchitecture of the bAVM. Even though it is generally accepted that the nidus of a ruptured bAVM may be underestimated in angiography during the acute phase due to hematoma compression, documentation of the underestimated parts has not been described in the literature. The authors report 2 cases of ruptured bAVMs in which the obscured segments were cast with liquid embolic material, which suggests a potential presence of obscured segments in bAVMs.

Costs and budget impact of collagen-based vascular closure device versus manual compression following peripheral endovascular procedures

OBJECTIVES

To evaluate the annual costs and budget impact of using a vascular closure device to achieve haemostasis following femoral access endovascular procedures in England, compared with manual compression.

METHODS

A budget impact model was developed in Microsoft® Excel, based on the estimated number of peripheral endovascular procedures eligible for day-case management performed annually by the National Health Service in England. The clinical effectiveness of vascular closure devices was captured based on the requirement for inpatient stays and the incidence of complications. Data for endovascular procedures, time to haemostasis, length of hospital stay, and complications were collected from public sources and the published literature. There were no patients involved in this study. Model outcomes are reported as estimated number of bed days and annual costs to the National Health Service for all peripheral endovascular procedures in England, and the average cost per procedure. The robustness of the model was tested in a sensitivity analysis.

RESULTS

The model estimated savings for the National Health Service of up to £4.5 million annually if vascular closure devices were used in every procedure instead of manual compression. The model estimated an average cost saving of £176 per procedure for vascular closure devices over manual compression, primarily due to fewer inpatient stays. The sensitivity analysis demonstrated that the proportion of day-case procedures for vascular closure devices and manual compression was a key driver of costs and savings.

CONCLUSIONS

The use of vascular closure devices for achieving haemostasis after peripheral endovascular procedures may be associated with lower resource use and cost burden, compared with manual compression, based on shorter time to haemostasis and ambulation and an increased likelihood of a day-case procedure.

Abdominal aortic endograft infection. A decade of experience and literature review

INTRODUCTION

Aortic endograft infection is an infrequent but life-threatening complication after endovascular abdominal aortic repair (EVAR). There is no consensus on management of endograft infection and little evidence has been published in our country. Endograft explantation is considered the "gold standar" treatment whereas percutaneous or surgical perigraft and sac drainage associated to antibiotics should be considered and alternative therapy.

METHODS

We carried out a retrospective and descriptive review of abdominal aortic endograft infections at our tertiary center (Hospital Universitario Cruces) during last ten years (2010-2019).

RESULTS

We describe the clinical and microbiological characteristics of 10 EVAR infections, their management and outcomes. The incidence of graft infection after EVAR was 3%. The mean time to the clinical presentation of infection was 16.9 months (median 4.5 months). The microbiological diagnosis was reached in 100% of cases (predominance of gram-positive species). The overall mortality rate was 50% (although the survival rate was 100% after surgical drainage of the sac).

CONCLUSION

Perigraft or aneurysm sac aspiration culture show their diagnostic utility as microbiological diagnosis was reached in all cases despite of blood cultures being only positive in 50% of the samples. Surgical drainage and endograft preservation combined with antibiotherapy show remarkable results. The high heterogeneity in our case series makes difficult to offer general recommendations, thus far, a tailored approach to treatment is suggested.

Prevalence of celiac artery compression by median arcuate ligament in patients with splanchnic artery aneurysms/pseudoaneurysms submitted to endovascular embolization

PURPOSE

To study the association between median arcuate ligament compression (MALC) of celiac artery (CA) and splanchnic artery aneurysms/pseudoaneurysms (SAAPs) submitted to endovascular embolization.

METHODS

Single center retrospective study of embolized SAAPs between 2010 and 2021, to evaluate the prevalence of MALC, and compare demographic data and clinical outcomes between patients with and without MALC. As a secondary objective, patient characteristics and outcomes were compared between patients with different causes of CA stenosis.

RESULTS

MALC was found in 12.3% of 57 patients. SAAPs were more prevalent in the pancreaticoduodenal arcades (PDAs) in patients with MALC, compared to those without MALC (57.1% vs. 10%, P = .009). Patients with MALC had a greater proportion of aneurysms (71.4% vs. 24%, P = .020), as opposed to pseudoaneurysms. Rupture was the main indication for embolization in both groups (71.4% and 54% of patients with and without MALC, respectively). Embolization was successful in most cases (85.7% and 90%), with 5 immediate (28.6% and 6%) and 14 non-immediate (28.6% and 24%) post-procedure complications. Thirty and 90-day mortality rate were 0% in patients with MALC, and 14% and 24% in patients without MALC. Atherosclerosis was the only other cause of CA stenosis, in 3 cases.

CONCLUSIONS

In patients with SAAPs submitted to endovascular embolization, the prevalence of CA compression by MAL is not uncommon. The most frequent location for aneurysms in patients with MALC is in the PDAs. Endovascular management of SAAPs is very effective in patients with MALC, with low complications, even in ruptured aneurysms.

Ruptured infective native thoracic aortic aneurysm treated by endovascular repair as a bridge therapy to open repair

We report the case of a 70-year-old woman who presented with a ruptured infective native thoracic aortic aneurysm (INTAA), associated with spondylodiscitis and posterior mediastinitis. She underwent a staged hybrid repair: urgent thoracic endovascular aortic repair was first performed as a bridge therapy in the context of septic shock. Allograft repair using cardiopulmonary bypass was performed five days later. Given the complexity of INTAA, multidisciplinary teamwork was paramount to determine the most appropriate treatment strategy, including procedure planning with multiple operators as well as perioperative care. Therapeutic alternatives are discussed.

Effects of statin use on primary patency, mortality, and limb loss in patients undergoing lower-limb arterial angioplasty: a systematic review and meta-analysis

BACKGROUD

Peripheral arterial disease can progress to critical limb ischemia, which requires revascularization. The endovascular approach is associated with a lower long-term patency due to restenosis resulting from neointimal hyperplasia. Statins offer significant advantages in patients undergoing percutaneous interventions. However, there are few studies on statin therapy associated with improved clinical outcomes after endovascular treatment in this patients.

AIM

This systematic review and meta-analysis examined the effects of statins (in comparison with no statin) on outcomes of lower-limb arterial angioplasty by evaluating patency, amputation and mortality.

METHOD

We searched MEDLINE, Academic Search Premier and CINAHL using a predetermined search strategy from inception to September 21, 2022. Study selection (first by title and abstract and then by full text) and data extraction was conducted by two independent reviewers. Risk of bias was assessed using the Newcastle-Ottawa Scale. According to data availability, we conducted meta-analysis using RevMan v.5.4.

RESULTS

The search identified 841 relevant articles and included 10 studies with 43,543 patients. Statin use in patients before undergoing lower-limb arterial angioplasty was associated with improved primary patency at 12 (12.57%, 95% confidence interval [CI] 6.86-18.28, p < 0.0001) and 24 months (7.19%, 95% CI 1.02-13.37, p = 0.02), decreased mortality in 39% at 12 months (relative risk (RR): 0.61, 95% CI 0.55-0.74, p < 0.00001) and decreased limb loss in 23% in the studied patients (RR: 0.77, 95% CI 0.65-0.91, p = 0.003).

CONCLUSION

Statin therapy before the procedure was associated with significantly improved patency and overall survival and decreased limb loss after lower-limb arterial angioplasty.

Percutaneous image-guided cryoablation with temporary balloon occlusion of the renal artery for the treatment of central renal tumors

PURPOSE

The purpose of this study was to report the technical feasibility and outcomes of percutaneous image-guided cryoablation with temporary balloon occlusion of the renal artery for the treatment of central renal tumors.

MATERIALS AND METHODS

All consecutive patients with central renal tumors treated with cryoablation and temporary renal artery occlusion from January 2017 to October 2021 were retrospectively included. Patient demographics, tumor's characteristics, procedural data, technical success, primary and secondary clinical efficacy, complications (according to Cardiovascular and Interventional Radiology Society of Europe [CIRSE] classification) and follow-up were investigated.

RESULTS

A total of 14 patients (8 men, 6 women; mean age 72.4 years ± 21.4 [SD] years; age range: 42-93 years) with 14 central renal tumors (median size, 32 mm; IQR: 23.5, 39.5 mm; range: 13-50 mm) were treated with percutaneous image-guided cryoablation and temporary balloon occlusion of the renal artery. Technical success was 13/14 (93%), with 1/14 (7%) failure of vascular access. A median of 4 cryoprobes (IQR: 3, 4.75) were inserted and protective hydrodissection was performed in 11/14 (79%) patients. Median time to perform cryoprobes insertion, hydrodissection and vascular access was 26.5 min (IQR: 18, 35 min), 10 min (IQR: 10, 17 min) and 30 min (IQR: 20, 45 min) respectively. Median duration of the whole intervention was 150 min (IQR: 129, 180 min; range: 100-270 min). Median hospital stay was 2.5 days (IQR: 2, 4 days; range: 2-14 days). Major complications occurred in 3/14 (21%) patients. Primary efficacy rate was 93% (13/14 patients). Median oncological follow-up was 25 months (IQR: 11, 33 months; range: 6-39 months). One patient experienced renal tumor recurrence at 14-months of follow-up, which was successfully treated with repeat cryoablation.

CONCLUSION

Percutaneous image-guided cryoablation of renal tumors with temporary balloon occlusion of the renal artery is technically feasible, with a high technical success rate and paths the way for percutaneous treatment of central renal tumors.

Stent-assisted coiling of a ruptured basilar artery perforator aneurysm: A case report

Basilar artery (BA) perforator aneurysms are exceedingly rare causes of subarachnoid hemorrhage. Therefore, the natural history and optimal treatment have not been established, and surgical, endovascular, and conservative management have been used. However, there is no consensus on the optimal treatment strategy. Herein, we report the case of a 52-year-old man presenting with a ruptured BA perforator aneurysm. First, we deployed an Enterprise stent from the left P1 segment to the BA because the microcatheter could not enter the aneurysm. Then, we deployed a helical coil on the orifice of the BA perforator. Finally, we deployed another Enterprise stent, sandwiching the helical coil between the two Enterprise stents. The aneurysm was completely obliterated without recurrence on the follow-up angiography. Our technique of sandwiching the small helical coil between two Enterprise stents might help other surgeons by offering another feasible treatment option for ruptured BA perforator aneurysms.

Effect of iliac tortuosity on outcomes after iliac branch procedures

OBJECTIVE

To report a two-centers evaluation of the effects of iliac axis tortuosity on iliac branch device (IBD) results.

METHODS

From 2015 to 2021, all IBD procedures performed at two European centers were analyzed retrospectively. The preoperative pelvic tortuosity index (PTI), external tortuosity index (ETI), and double iliac sign (DIS) were assessed for each iliac axis submitted to IBD. The primary endpoints were technical success, early and mid-term IBD complications (occlusion, stenosis, endoleaks [ELs]) and reinterventions, and the association with the PTI, ETI, and DIS. The 30-day mortality, survival, freedom from complications and freedom from reinterventions (FFR) were the secondary endpoints.

RESULTS

During the study period, 224 patients had undergone 256 IBD procedures for 165 (64.5%) aortoiliac aneurysms, 44 (17.2%) isolated iliac aneurysms, 11 (4.3%) abdominal aortic aneurysms with a short iliac landing zone, and 36 (14.1%) type Ib ELs. IBD was planned with endovascular aortic aneurysm repair for 158 (61.7%), fenestrated/branched endovascular aortic aneurysm repair for 45 (7.6%), and isolated for 53 (20.7%) cases. Technical success and 30-day mortality were 99.2% (254 of 256) and 0.9% (2 of 224), respectively. A PTI >1.4, an ETI >1.7, and the DIS were tested to identify the risk factors for the endpoints. No ELs and 9 (3.5%) IBD occlusions, requiring five reinterventions (2%), had occurred within 30 days. No association with the PTI, ETI, or DIS was identified; IBD oversizing of ≥25% on the external iliac artery was independently related to occlusion (odds ratio, 4.3; 95% confidence interval [CI], 1-18.1; P = .045). The mean follow-up was 31 ± 27 months, with 11 IBD occlusions, 14 ELs, and 21 reinterventions. At 1, 3, and 5 years of follow-up survival, IBD patency, and FFR were 95%, 89%, and 80%; 93%, 91%, and 90%; and 93%, 89%, and 83%, respectively. The risk factors for overall complications (n = 34; 13.3%) and reinterventions (n = 26; 10.2%) were an ETI >1.7 (P = .037 and P = .019), a PTI >1.4 (P = .016 and P = .012), and a type Ib EL as the indication (P = .025 and P = .001), respectively. Cox regression confirmed PTI >1.4 as an independent predictor of overall complications and reinterventions (hazard ratio [HR], 2.3; 95% CI, 1.1-4.4; P = .018; and HR, 3 95% CI, 1.3-6.8; P = .018, respectively) and ETI >1.7 as an independent risk factor for ELs (HR 6; 95% CI, 2.1-17.5; P = .001). The freedom from complications and FFR were significantly lower with a PTI >1.4 at 3 years (73% vs 92% [log-rank P = .01] and 77% vs 93% [log-rank P = .001], respectively).

CONCLUSIONS

We found IBDs to be safe and effective in the treatment of aortoiliac aneurysms. Early complications are uncommon and related to endograft oversizing rather than anatomic characteristics in the present study. Iliac tortuosity is a risk factor for overall complications and reinterventions, in particular for IBD-related ELs.

Preoperative Transvenous Liquid Embolization for a Symptomatic Lumbar Spinal Epidural Varix Mimicking Radiculopathy

BACKGROUND

Symptomatic spinal epidural veins (SEV) are a rare cause of neurologic dysfunction. Treatment is centered upon addressing the underlying venous pathology to relieve mechanical compression of the neurologic structures. However, open surgical ligation is often associated with considerable blood loss.

OBJECTIVE

We discuss a unique case of a large symptomatic epidural venous varix and potential treatment strategy.

METHODS AND MATERIALS

A 15-year-old female presented with a 1-year history of left L5 radicular pain and weakness. Lumbar MRI demonstrated a central L5/S1 herniated disc and a large extradural anomalous SEV compressing the exiting left L5 nerve root at the L5/S1 neuroformina. The SEV was treated using a transvenous liquid embolic agent providing symptomatic relief. At 16-months follow-up, she reported recurrent symptoms. She ultimately underwent a left L5/S1 MIS decompression without complication.

CONCLUSION

Transvenous liquid embolization of large symptomatic SEV may provide temporary neurologic relief and decrease morbidity associated with open surgical treatment options.

Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study

OBJECTIVE

The Dutch Surgical Aneurysm Audit (DSAA) initiative was established in 2013 to monitor and improve nationwide outcomes of aortic aneurysm surgery. The objective of this study was to examine whether outcomes of surgery for intact abdominal aortic aneurysms (iAAA) have improved over time.

METHODS

Patients who underwent primary repair of an iAAA by standard endovascular (EVAR) or open surgical repair (OSR) between 2014 and 2019 were selected from the DSAA for inclusion. The primary outcome was peri-operative mortality trend per year, stratified by OSR and EVAR. Secondary outcomes were trends per year in major complications, textbook outcome (TbO), and characteristics of treated patients. The trends per year were evaluated and reported in odds ratios per year.

RESULTS

In this study, 11 624 patients (74.8%) underwent EVAR and 3 908 patients (25.2%) underwent OSR. For EVAR, after adjustment for confounding factors, there was no improvement in peri-operative mortality (aOR [adjusted odds ratio] 1.06, 95% CI 0.94 - 1.20), while major complications decreased (2014: 10.1%, 2019: 7.0%; aOR 0.91, 95% CI 0.88 - 0.95) and the TbO rate increased (2014: 68.1%, 2019: 80.9%; aOR 1.13, 95% CI 1.10 - 1.16). For OSR, the peri-operative mortality decreased (2014: 6.1%, 2019: 4.6%; aOR 0.89, 95% CI 0.82 - 0.98), as well as major complications (2014: 28.6%, 2019: 23.3%; aOR 0.95, 95% CI 0.91 - 0.99). Furthermore, the proportion of TbO increased (2014: 49.1%, 2019: 58.3%; aOR 1.05, 95% CI 1.01 - 1.10). In both the EVAR and OSR group, the proportion of patients with cardiac comorbidity increased.

CONCLUSION

Since the establishment of this nationwide quality improvement initiative (DSAA), all outcomes of iAAA repair following EVAR and OSR have improved, except for peri-operative mortality following EVAR which remained unchanged.

Long-Term Outcomes of Placement of a Single Transverse Stent through the Anterior Communicating Artery via the Nondominant A1 in Coil Embolization of Wide-Necked Anterior Communicating Artery Aneurysms

Objective

Placement of a single transverse stent via the nondominant A1 across the anterior communicating artery (AComA) into the contralateral A2 can provide sufficient neck coverage for wide-necked bifurcation AComA aneurysms. The authors described the feasibility, safety and long-term outcomes of this technique.

Methods

Between January 2015 and February 2018, placement of a single transverse stent via the nondominant A1 was attempted in 17 wide-necked bifurcation AComA aneurysms. The authors reviewed the medical records and radiological studies.

Results

The technical success rate was 94.1% (16/17). Periprocedural thromboembolic complications occurred in one patient (6.3%) without permanent neurological deficits. The mean clinical follow-up duration was 39.9±9.8 months. No deaths or delayed thromboembolic complications occurred. The mean angiographic follow-up duration was 38.9±9.8 months. The immediate and final follow-up complete occlusion rates were 87.4 and 93.7%, respectively. There was no recanalization during the follow-up period.

Conclusion

Placement of a single transverse stent via the nondominant A1 across the AComA into the contralateral A2 is a feasible and relatively safe endovascular technique for the treatment of wide-necked bifurcation AComA aneurysms, with good long-term occlusion rates and a reasonable complication rate, if only the nondominant A1 is applicable.

Comparative effectiveness of endovascular treatment modalities for de novo femoropopliteal lesions in intermittent claudication: A network meta-analysis of randomized controlled trials

PURPOSE

To evaluate the most effective endovascular treatment modalities for de novo femoropopliteal lesions in intermittent claudication (IC) in terms of technical success, primary patency, target lesion revascularization (TLR) and all-cause mortality through network meta-analysis of randomized controlled trials.

METHODS

Medical databases were searched on December 3, 2020. 16 studies (3265 patients) and 7 treatments were selected. Outcomes were technical success, primary patency, TLR and mortality at 6 and/or 12 months.

RESULTS

Regarding 6-month primary patency, drug-eluting stents (DES) was better than balloon angioplasty (BA; odds ratio [OR], 23.27; 95% confidence interval [CI], 12.57-43.06), drug-coated balloons (DCB; OR, 5.63; 95% CI, 2.26-14.03) and directional atherectomy (DA; OR, 31.52; 95% CI, 7.81-127.28), and bare nitinol stents (BNS) was better than BA (OR, 17.91; 95% CI, 7.22-44.48), DCB (OR, 4.33; 95% CI, 1.40-13.45) and DA (OR, 24.27; 95% CI, 5.16-114.11). Regarding 12-month primary patency, DES was better than BA (OR, 10.05; 95% CI, 4.56-22.16), DCB (OR, 3.70; 95% CI, 1.54-8.89) and DA (OR, 29.54; 95% CI, 7.26-120.26). DCB and combination of balloon and atherectomy were the most effective treatment regarding 12-month TLR and technical success (residual stenosis <30%), respectively. DES, BNS and DA with DCB (DA-DCB) were included in the best cluster in the clustered ranking plot combining 12-month primary patency and TLR.

CONCLUSIONS

Balloon and atherectomy may confer advantages over other treatments for technical success; DCB may for TLR. Stent technologies confer substantial advantages regarding primary patency. Stent technologies and DA-DCB should be given priority in treating femoropopliteal lesions in IC.

Anastomosis and Endovascular Treatment of Iatrogenic Vertebral Artery Injury

Iatrogenic vertebral artery injury (VAI) that occurs during cervical spine surgery can cause life-threatening complications, such as arteriovenous fistulas, catastrophic bleeding, neurological impairment, cerebral ischemia, and death. We report a case of dominant VAI during surgery and the treatment of a 60-year-old man diagnosed with a C1-2-3 metastatic spine tumor from urothelial carcinoma. Active bleeding occurred during tumor resection using pituitary forceps, immediately followed by gauze packing and manual compression. Post further resection, we found that the vertebral artery (VA) was completely severed. After temporary clamping on both sides of the damaged VA, an artificial graft anastomosis was performed. After verifying that the flow was intact using Doppler Sonography, Occiput-C1-4-5-6 posterolateral fusion was performed. Angiography was performed immediately after surgery. We found a thrombus occluding the left VA, and performed mechanical thrombectomy and stent insertion. The final angiography showed good VA flow with no emboli. In this case, VA anastomosis and endovascular treatment were performed within a relatively short period of time post VAI, and the patient was able to recover without any neurological deficits.

Safety and Validity of the Proposed European Society for Vascular Surgery Infrarenal Endovascular Aneurysm Repair Surveillance Protocol: A Single Centre Evaluation

OBJECTIVE

Long term surveillance after endovascular aneurysm repair (EVAR) is essential to detect late complications, but there is variation in practice. The European Society for Vascular Surgery (ESVS) made a recommendation for a new surveillance protocol; one element involves risk stratifying patients depending on sac size reduction and presence of endoleak at their 30 day computed tomography angiogram into low risk groups (delayed imaging to five years) or higher risk groups (continue with the current protocol). The aim was to test this suggested protocol retrospectively within an EVAR patient cohort.

METHODS

Data on EVARs performed from October 2009 to October 2019 were collected. Information gathered from an existing surveillance programme was used to assess the proposed ESVS protocol. All patients who underwent re-intervention were reviewed to see whether adopting the proposed ESVS protocol would have detected these events.

RESULTS

In total, 309 procedures were included. Altogether, 219 of these patients had no endoleak (70.9%) and 86 had a type II (27.8%) endoleak. Only four developed a type I or III endoleak. No patient in the low risk cohort (no initial endoleak or sac shrinkage > 1 cm) required secondary intervention. Five year follow up data were available for 103 patients. In the type II endoleak group, there were 28 secondary interventions in 22 patients. No patient experienced a ruptured aneurysm within five years post-operatively. Had the proposed ESVS protocol been followed, all patients requiring a secondary intervention or with increasing sac size would have been detected/captured. Further, adherence to the ESVS guidelines would have resulted in 103 patients with a five year follow up history qualifying for reduced surveillance. A further 120 patients who had reached the three and four year follow up timepoints could have qualified for a reduced surveillance, reducing imaging cost further.

CONCLUSION

Adopting the proposed ESVS EVAR surveillance protocol safely identified "low risk" patients who did not go on to require a secondary intervention. These patients could benefit from reduced surveillance scanning.

Spinal cord hemodynamic infarction after vertebral artery endovascular trapping despite preserved flow in the anterior spinal artery

Context: Spinal cord infarction is a rare condition that develops as a result of insufficient vascular perfusion, sometimes related to procedures involving the aorta and vertebral arteries.Findings: We present the case of a 66-year-old woman who developed weakness on all four extremities and thermalgesic sensory deficit following an elective endovascular embolization of an incidentally diagnosed aneurysm in the posterior circulation. The procedure involved the cathetherization of both vertebral arteries, but was unremarkable and the flow into the anterior spinal artery was preserved. Radiological findings highly suggested a spinal cord infarction. She was started on corticosteroids and showed a significant neurological improvement.Clinical relevance: The present case illustrates that spinal cord infarction is a typical - but uncommon - complication that has to be suspected after vertebral artery endovascular procedures. It can result from hypoperfusion of smaller branches that irrigate the cervical spinal cord, and patients can make remarkable recoveries despite severe initial deficits.

Factors associated with rebleeding after coil embolization in patients with aneurysmal subarachnoid hemorrhage

Objective

Aneurysmal subarachnoid hemorrhage (aSAH) has a high mortality rate, and hemorrhage amounts and perioperative rebleeding importantly determines prognosis. However, despite adequate treatment, prognosis is poor in many ruptured aneurysm cases. In this study, we identified and evaluated factors related to perioperative rebleeding in patients with aSAH.

Methods

The medical and surgical records of 166 patients that underwent endovascular embolization for a ruptured cerebral aneurysm at a single institution from 2014 to 2016 were retrospectively analyzed to identify risk factors of rebleeding. All patients were examined for risk factors and evaluated for increased hemorrhage by brain computed tomography at 3 days after surgery.

Results

This series included 54 men (32.5%) and 112 women (67.5%) of mean age 58.3±14.3 years. After procedures, 26 patients (15.7%) experienced rebleeding, and 1 of these (0.6%) experienced an intraoperative aneurysmal rupture. External ventricular drainage (EVD) (odds ratio [OR] 5.389, [95% confidence interval (CI) 1.171- 24.801]) and modified Fisher grade (OR 2.037, [95% CI 1.077-3.853]) were found to be independent risk factors of rebleeding, and perioperative rebleeding was strongly associated with patient outcomes (p＜0.001).

Conclusions

We concluded the rebleeding risk after aSAH is greater in patients with large hemorrhage amounts and a high pre-operative modified Fisher grade, and thus, we caution neurosurgeons should take care in such cases.

Long Term Outcomes of Post-Implantation Syndrome After Endovascular Aneurysm Repair

OBJECTIVE

The aim of this study was to investigate the association between post-implantation syndrome (PIS) and long term outcomes, with emphasis on cardiovascular prognosis.

METHODS

One hundred and forty-nine consecutive patients undergoing EVAR in a tertiary institution were previously included in a study investigating the risk factors and short term consequences of PIS (defined as tympanic temperature ≥ 38°C and CRP > 10 mg/L, after excluding complications with an effect on inflammatory markers). This study was based on a prospectively maintained database. Survival status was derived from inquiry of civil registry database information and causes of death from the Dutch Central Bureau of Statistics. The primary endpoint was cardiovascular events. Secondary endpoints were overall and specific cause mortality (cardiovascular, ischaemic heart disease, AAA, and cancer related mortality). Aneurysm sac dynamics and occurrence of endoleaks were also analysed. Survival estimates were obtained using Kaplan-Meier plots and a multivariable model was constructed to correct for confounders.

RESULTS

The PIS incidence was 39% (58/149). At the time of surgery, patients had a mean age of 73 ± 7 years and were predominantly male. There were no baseline differences between the PIS and non-PIS groups. The median follow up was 6.4 years (3.2 - 8.3), similar in both groups (p = .81). There was no difference in cardiovascular events for PIS and non-PIS patients (p = .63). However, Kaplan-Meier plots suggest a trend towards a higher rate of cardiovascular events in PIS patients during the first years: freedom from cardiovascular events at one year was 94% vs. 89% and at three years 90% vs. 82%. No differences were found in overall and specific cause mortality. There was a higher rate of type II endoleaks for non-PIS patients (28% vs. 9%, p = .005). Sac dynamics were similar in both groups.

CONCLUSION

The results suggest that PIS is not associated with a statistically significantly higher risk of cardiovascular events. PIS had no impact on mortality. Lastly, PIS patients had fewer type II endoleaks, but sac dynamics were analogous.

Abdominal aortic endograft infection. A decade of experience and literature review

INTRODUCTION

Aortic endograft infection is an infrequent but life-threatening complication after endovascular abdominal aortic repair (EVAR). There is no consensus on management of endograft infection and little evidence has been published in our country. Endograft explantation is considered the "gold standard" treatment whereas percutaneous or surgical perigraft and sac drainage associated to antibiotics should be considered and alternative therapy.

METHODS

We carried out a retrospective and descriptive review of abdominal aortic endograft infections at our tertiary center (Hospital Universitario Cruces) during last ten years (2010-2019).

RESULTS

We describe the clinical and microbiological characteristics of 10 EVAR infections, their management and outcomes. The incidence of graft infection after EVAR was 3%. The mean time to the clinical presentation of infection was 16.9 months (median 4.5 months). The microbiological diagnosis was reached in 100% of cases (predominance of gram-positive species). The overall mortality rate was 50% (although the survival rate was 100% after surgical drainage of the sac).

CONCLUSIONS

Perigraft or aneurysm sac aspiration culture shows their diagnostic utility as microbiological diagnosis was reached in all cases despite of blood cultures being only positive in 50% of the samples. Surgical drainage and endograft preservation combined with antibiotherapy show remarkable results. The high heterogeneity in our case series makes difficult to offer general recommendations, thus far, a tailored approach to treatment is suggested.

Navigability of a long sheath in the lateral dural sinuses facilitated by the pilot balloon technique: technical note

Dural sinus stenting is an increasingly recognized intervention for the treatment of lateral sinus stenosis. This procedure can be challenging in tortuous anatomy and in the presence of intraluminal septa because of poor trackability and crossability of long sheath commonly used for stenting. We report a technique using a pilot angioplasty balloon positioned at the distal end of the long sheath that improves its navigability in dural sinuses and facilitated the intervention.

Factors contributing to efficient recanalization procedures for chronic total occlusion of the superficial femoral artery

BACKGROUND

This study aimed to clarify the factors for efficient procedures (EP) in superficial femoral artery (SFA) chronic total occlusion (CTO).

METHODS

We retrospectively analyzed 200 consecutive limbs that underwent treatment for SFA CTO. The patients were divided into three groups according to the main strategies: subintimal angioplasty (SIA) (n = 123), Crosser use (n = 50), and 0.014″ CTO guidewire (CTO-GW) (n = 27). To determine the factors for an EP (EP; contrast volume <130 mL and procedure time <20 min; derived from non-CTO [control] procedures), the variables (P < 0.2) underwent multivariate analysis.

RESULTS

SIA included more Trans-Atlantic Inter-Society Consensus C/D lesions and contralateral femoral approaches, and additional GW use (P < 0.05). CTO-GW presented a shorter occlusion length and elapsed time, and used less retrograde approach than the other strategies (P < 0.05). Crossers had a higher incidence of perforation (P = 0.002). The prompt retrograde approach had a similar actual retrograde procedure time, but a shorter total procedure time, compared to that of the delayed adoption (P < 0.001). EP was achieved in 14 limbs (7.0%). Multivariate analysis revealed that occlusion length (adjusted odds ratio [OR], 0.89; 95% CI, 0.81-0.96; P = 0.004) and SIA (OR, 8.71; 95% CI, 1.32-175.27; P = 0.02) were associated with EP.

CONCLUSIONS

SIA contributed to EP. The timing of the retrograde approach was crucial because its delay resulted in an excessive procedure time.

Preoperative statin therapy is associated with higher 5-year survival after thoracic endovascular aortic repair

OBJECTIVE

Statin use is associated with higher long-term survival after abdominal aortic aneurysm repair. However, the association between statin use and survival after thoracic endovascular aortic repair (TEVAR) has not been established.

METHODS

We performed a review of prospectively collected data of all patients who had undergone TEVAR in the Vascular Quality Initiative between 2014 and 2020. We excluded patients aged <18 years, those who had presented with trauma, and those who had received custom-manufactured or physician-modified devices. We evaluated the association between preoperative statin therapy and in-hospital mortality and complications and 5-year mortality. We also analyzed the trend of preoperative statin use in elective cases for the previous 7 years. To account for nonrandom assignment to treatment, we used propensity score matching of patient characteristics, comorbidities, pathology, and urgency for preoperative statin use. We used logistic regression and Cox regression for the short-term and 5-year outcomes, respectively.

RESULTS

Of 6266 patients who had undergone TEVAR and met the inclusion criteria, 3331 (53%) patients had been taking a statin preoperatively, including 1148 of 2267 (64%) treated for aneurysmal disease. After propensity score matching, 1875 patients were in each cohort. Preoperative statin use was associated with lower rates of any perioperative complication (16.7% vs 19.6%; odds ratio, 0.82; 95% confidence interval [CI] 0.69-0.97; P = .022). Overall, preoperative statin use was also associated with lower 5-year mortality (18.8% vs 24.5%; hazard ratio [HR], 0.74; 95% CI, 0.63-0.89; P = .001). When stratified by urgency, preoperative statin use was associated with lower 5-year mortality after elective TEVAR (14.9% vs 22.4%; HR, 0.62; 95% CI, 0.49-0.79; P < .001) but not after urgent or emergent TEVAR (27.4% vs 29.1%; HR, 0.89; 95% CI, 0.70-1.14; P = .37). When stratified by pathology, preoperative statin use was associated with significantly lower 5-year mortality for patients with aneurysms (HR, 0.63; 95% CI, 0.48-0.83; P = .001). Although the mortality was also lower for patients with dissection and "other" pathology, these differences did not reach statistical significance. Between 2014 and 2019, a significant increase had occurred in statin use among patients undergoing elective TEVAR, from 56% in 2014 to 64% in 2019 (P = .007).

CONCLUSIONS

Preoperative statin therapy is associated with lower perioperative complication rates and 5-year mortality for patients undergoing TEVAR. All patients with known thoracic aortic pathology should receive statin therapy unless contraindications for the drug are present. For patients undergoing elective TEVAR, the statin prescription percentage should be considered a quality metric, and further implementation research should occur to improve preoperative statin use.

Conformability of the GORE EXCLUDER iliac branch endoprosthesis is associated with freedom from adverse iliac events

OBJECTIVE

The GORE EXCLUDER iliac branch endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Ariz) is designed to preserve internal iliac artery (IIA) patency during endovascular treatment of aneurysms involving the common iliac artery. The device is intended to conform to iliac tortuosity, which may decrease adverse iliac events (AIE). The objective of this study was to evaluate risk factors for AIE after IBE implantation.

METHODS

This was a post hoc analysis of the prospective, multicenter GORE 12-04 IBE pivotal trial. Patients with preoperative and postoperative axial imaging were included, with analysis based on each treated iliac system. An independent core laboratory performed all scan measurements, including iliac diameters, lengths, and tortuosity. Conformability was analyzed by the changes in tortuosity after IBE deployment, with less change indicating greater conformation. The end point was AIE, defined as ipsilateral radiographic or clinical complications. Critical nonconformation was defined as a threshold change in tortuosity associated with a significant increase in AIE.

RESULTS

We included 98 patients with 101 treated iliac systems. There were eight AIE (8%; six IIA component occlusions, one iliac branch component occlusion, and one EIA dissection requiring reintervention). Patients with AIE had smaller IIA diameters and less IBE conformability. After multivariable logistic regression analysis, an IIA diameter of less than 10 mm and a change in total iliac tortuosity beyond -15% were independently associated with AIE (odds ratio, 12 [interquartile range, 1.4-110] and odds ratio, 8.2 [interquartile range, 1.5-46], respectively), and the latter was used to define critical nonconformation. Critical nonconformation occurred in 11% of treated systems, and was associated with a high rate of AIE (36% vs 4%; P = .004).

CONCLUSIONS

Endograft conformation is a novel device property and technical outcome that, along with a larger IIA diameter, is associated with freedom from AIE after IBE deployment. An evaluation of these risk factors may better inform the management of patients with iliac aneurysmal disease. Further research on endograft conformation and patient outcomes is warranted, particularly for those with challenging anatomy undergoing complex procedures.

Use of second generation supraglottic airway device for endovascular treatment of unruptured intracranial aneurysms: a retrospective cohort

Background

We aimed to assess the feasibility of using supraglottic devices as an alternative to orotracheal intubation for airway management during anesthesia for endovascular treatment of unruptured intracranial aneurisms in our department over a nine-year period.

Methods

Retrospective single center analysis of cases (2010–2018). Primary outcomes: airway management (supraglottic device repositioning, need for switch to orotracheal intubation, airway complications). Secondary outcomes: aneurysm complexity, history of subarachnoid hemorrhage, hemodynamic monitoring, and perioperative complications.

Results

We included 187 patients in two groups: supraglottic device 130 (69.5%) and orotracheal intubation 57 (30.5%). No adverse incidents were recorded in 97% of the cases. Three supraglottic device patients required supraglottic device repositioning and 1 supraglottic device patient required orotracheal intubation due to inadequate ventilation. Three orotracheal intubation patients had a bronchospasm or laryngospasm during awakening. Forty-five patients (24.1%) had complex aneurysms or a history of subarachnoid hemorrhage. Thirty-three of them (73.3%) required orotracheal intubation compared to 24 of the 142 (16.9%) with non-complex aneurysms. Two patients in each group died during early postoperative recovery. Two in each group also had intraoperative bleeding. A post-hoc analysis showed that orotracheal intubation was used in 55 patients (44%) in 2010 through 2014 and 2 (3.2%) in 2015 through 2018, parallel to a trend toward less invasive blood pressure monitoring from the earlier to the later period from 34 (27.2%) cases to 5 (8.2%).

Conclusion

Supraglottic device, like other less invasiveness protocols, can be considered a feasible alternative airway management approach in selected patients proposed for endovascular treatment of unruptured intracranial aneurisms.

Outcomes in Octogenarians and the Effect of Comorbidities After Intact Abdominal Aortic Aneurysm Repair in the Netherlands: A Nationwide Cohort Study

OBJECTIVE

Age is an independent risk factor for mortality after both elective open surgical repair (OSR) and endovascular aneurysm repair (EVAR). As a result of an ageing population, and the less invasive nature of EVAR, the number of patients over 80 years (octogenarians) being treated is increasing. The mortality and morbidity following aneurysm surgery are increased for octogenarians. However, the mortality for octogenarians who have either low or high peri-operative risks remains unclear. The aim of this study was to provide peri-operative outcomes of octogenarians vs. non-octogenarians after OSR and EVAR for intact aneurysms, including separate subanalyses for elective and urgent intact repair, based on a nationwide cohort. Furthermore, the influence of comorbidities on peri-operative mortality was examined.

METHODS

All patients registered in the Dutch Surgical Aneurysm Audit (DSAA) undergoing intact AAA repair between 2013 and 2018, were included. Patient characteristics and peri-operative outcomes (peri-operative mortality, and major complications) of octogenarians vs. non-octogenarians for both OSR and EVAR were compared using descriptive statistics. Multivariable logistic regression analyses were used to examine whether age and the presence of cardiac, pulmonary, or renal comorbidities were associated with mortality.

RESULTS

This study included 12 054 EVAR patients (3 015 octogenarians), and 3 815 OSR patients (425 octogenarians). Octogenarians in both the EVAR and OSR treatment groups were more often female and had more comorbidities. In both treatment groups, octogenarians had significantly higher mortality rates following intact repair as well as higher major complication rates. Mortality rates of octogenarians were 1.9% after EVAR and 11.8% after OSR. Age ≥ 80 and presence of cardiac, pulmonary, and renal comorbidities were associated with mortality after EVAR and OSR.

CONCLUSION

Because of the high peri-operative mortality rates of octogenarians, awareness of the presence of comorbidities is essential in the decision making process before offering aneurysm repair to this cohort, especially when OSR is considered.

Pulmonary angioplasty: A step further in the continuously changing landscape of chronic thromboembolic pulmonary hypertension management

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially fatal and frequently undiagnosed form of pulmonary hypertension (PH), classified within group 4 by the World Health Organization (WHO). It is a type of precapillary PH, which uncommonly develops as a peculiar sequel of acute pulmonary embolism due to the partial resolution of the mechanically obstructing thrombus with a coexisting inflammatory response from pulmonary vessels. CTEPH is one of the potentially treatable forms of PH whose current standard of care is surgical pulmonary endarterectomy. Medical therapy with few drugs in non-operable disease is approved and has shown improvement in patients' hemodynamic condition and functional ability. Recently, balloon pulmonary angioplasty (BPA) has shown promising results as a treatment option for technically inoperable patients, those with unacceptable risk-to-benefit ratio and in a case of residual PH after endarterectomy. Lack of meticulous CTEPH screening programs in post-pulmonary embolism patients leading to underdiagnosis of this condition, complex operability assessment, and diversity in BPA techniques among different institutions are still the issues that need to be addressed. In this paper, we review the recent achievements in the management of non-operable CTEPH, their outcome and safety, based on available data.

Distal radial access for cerebral aneurysm embolization

OBJECTIVES

To demonstrate the feasibility and safety of distal radial access for embolization of ruptured and unruptured cerebral aneurysms.

METHODS

This study is a retrospective review of our prospective cerebral aneurysm embolization database. Between January and September 2019, distal radial access was considered for consecutive subjects addressed for cerebral aneurysm embolization at our institution. All procedures were performed by the same experienced operator. Technical success was defined as distal radial access with insertion of the sheath and completion of the intervention without change of access site to conventional femoral access. Primary safety endpoint was the in hospital + 30 days incidence of radial artery occlusion. Secondary endpoints included intra-procedural complications and neurologic complications at discharge and at 30 days.

RESULTS

Fifty-seven patients with cerebral aneurysms underwent 61 embolization procedures. Twenty eight embolizations were performed using coils, 8 used a stent-assisted coil technique, 22 used a balloon-assisted coil technique, and 3 used a flow diverter. One patient (1.6%) required crossover to femoral access. Three patients developed coil-induced thrombus that required intra-arterial Tirofiban injections. Two patients were asymptomatic and one patient presented confusion due to right frontal ischemia. One periprocedural aneurysm rupture occurred without clinical impact. Radial artery occlusion and hand ischemia were not observed.

CONCLUSION

Findings of the present study showed the feasibility of distal transradial access for cerebral aneurysm embolization without increasing the risk of the procedure.

Efficacy of endovascular embolization of arterial pseudoaneurysms in pancreatitis: A systematic review and meta-analysis

BACKGROUND

There is a significant variability in the reported outcomes following endovascular embolization of arterial pseudoaneurysms in pancreatitis. The objective of this systematic review and meta-analysis is to evaluate the efficacy of endovascular embolization of pancreatitis-related pseudoaneurysms.

METHODS

Searches of MEDLINE, EMBASE, and SCOPUS databases were performed through July 1, 2019 in accordance with PRISMA guidelines. All studies with ≥10 patients reporting technical success, clinical success, complications, and mortality were included. Generalized linear mixed method with random effects model was used for assessing pooled incidence rates and corresponding 95% confidence intervals (CIs).

RESULTS

A total of 29 studies (n = 840 with 638 pseudoaneurysms) were included. The pooled incidence rates of pseudoaneurysms in acute and chronic pancreatitis were 0.05% and 0.03%, respectively (odds ratio, 0.91, 95% CI-0.24-3.43). The most common site of pseudoaneurysm was splenic artery (37.7%). The most common embolization agent was coil (n = 415). The follow up period was 54.7 months (range, 21 days to 40.5 months). Pooled technical success rate was 97% (95% CI-92-99%, I² 83%). Clinical success rates at ≤3 months, 3-12 months, and >12 months were 82% (95% CI-70-90%, I² 42%), 86% (95% CI-75-92%, I² 44%), and 88% (95% CI-83-91%, I² 0%), respectively. There was no significant difference in the technical or clinical success between acute and chronic pancreatitis on subgroup analysis. Mortality was lower in chronic pancreatitis (OR 4.27 (95% CI 1.35-13.53, I² 0%)). Splenic infarction was the most common complication (n = 47).

CONCLUSION

Endovascular embolization is associated with a high technical and clinical success.

Association between Body Mass Index and Clinical Outcomes of Peripheral Artery Disease after Endovascular Therapy: Data from K-VIS ELLA Registry

We investigated the association between body mass index and clinical outcomes of peripheral artery disease (PAD) after endovascular therapy (EVT). A total of 2914 PAD patients undergoing EVT were participated according to body mass index groups. Underweight was significantly associated with increased risk of major adverse cardiovascular events (MACE) (adjusted hazard ratio [HR], 1.540; 95% confidence interval [CI], 1.091–2.173) and major adverse limb events (MALE) (adjusted HR, 1.523; 95% CI, 1.066–2.177) compared with normal weight. Plus, overweight was associated with lower risk of MACE and not with MALE. However, obesity showed no significant association with MACE or MALE.

Background and Objectives

Few studies have investigated the obesity paradox in clinical outcomes of peripheral artery disease (PAD). We investigated the association between body mass index (BMI) and clinical outcomes in PAD patients undergoing endovascular therapy (EVT).

Methods

Patients (n=2,914) from the retrospective Korean Vascular Intervention Society Endovascular Therapy in Lower Limb Artery Disease registry were categorized according to BMI: underweight (<18.5 kg/m², n=204), normal weight (18.5–25 kg/m², n=1,818), overweight (25–30 kg/m², n=766), or obese (≥30 kg/m², n=126). Groups were compared for major adverse cardiovascular events (MACE) and major adverse limb events (MALE).

Results

The underweight and obese groups were older and had more frequent critical limb ischemia and infrapopliteal artery disease than the normal or overweight groups (all p<0.001). Hypertension and diabetes were more frequent and current smoking was less frequent in the overweight and obese groups than the underweight or normal weight groups (all p <0.001). The underweight group showed the higher rates of MACE and MALE at 3 years (17.2%, 15.7%) compared with the normal weight (10.8%, 11.7%), overweight (8.4%, 10.7%), or obese groups (8.7%, 14.3%) (log-rank p<0.001, p=0.015). In contrast, the risk of MACE was lower in the overweight than the normal weight group (adjusted hazard ratio, 0.706; 95% CI, 0.537–0.928).

Conclusions

In PAD patients undergoing EVT, underweight was an independent predictor for MACE and MALE, whereas MACE risk was lower for overweight than normal weight patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT02748226

Safety of heparin loading during endovascular embolization in patients with aneurysmal subarachnoid hemorrhage

OBJECTIVE

Of the complications that can occur during endovascular surgery in aneurysmal subarachnoid hemorrhage (aSAH) patients, thromboembolism remains a particular challenge for many surgeons. Heparin has been widely used for its prevention, but it has not been able to eliminate concerns about bleeding. Therefore, in this study, we tried to determine the risk of rebleeding associated with heparin use.

METHODS

We retrospectively analyzed the medical and surgical records of 109 patients that underwent endovascular embolization for a ruptured cerebral aneurysm at a single institution from 2010 to 2014. These patients were divided into two groups according to whether heparin was loaded or not, to determine the effect of heparin on rebleeding and to identify other risk factors of rebleeding.

RESULTS

This series included 40 men (36.7 %) and 69 women (63.3 %) of mean age 57.9 ± 14.8 years. In 80 patients (73.4 %), endovascular embolization was conducted using an intraoperative bolus of 5000 units of heparin, whereas in the other 29 (26.6 %) endovascular embolization was performed without an intraoperative heparin bolus. After procedures, 16 patients (14.7 %) experienced rebleeding and 2 (1.8 %) a thromboembolic event. Intraoperative heparin loading (OR 0.683 [95 % CI 0.199-2.338]) was not found to be related to postoperative rebleeding. Rather, logistic regression analysis showed preoperative modified Fisher grade (OR 2.037 [95 % CI 1.077-3.853]) and external ventricular drainage (OR 5.389 [95 % CI 1.171-24.801]) independently predicted rebleeding.

CONCLUSIONS

Heparin loading during endovascular treatment of ruptured cerebral aneurysms did not affect rebleeding. We conclude heparin loading to prevent thromboembolism during endovascular treatment may be considered a good option in aSAH patients.

Antithrombotic medication and endovascular interventions associated with short-term exposure to particulate air pollution: A nationwide case-crossover study

Short-term exposure to air pollution has pro-thrombotic effects and triggers thrombo-embolic events such as myocardial infarction or stroke in adults. This study evaluates the association between short-term variation in air pollution and treatments for acute thrombo-embolic events among the whole Belgian population. In a bidirectional time-stratified case-crossover design, we included 227,861 events treated with endovascular intervention and 74,942 with antithrombotic enzymes that were reimbursed by the Belgian Social Security between January 1st, 2009 and December 31st, 2013. We compared the concentrations of particulate matter (PM) air pollution (PM₁₀ and PM_2.5), as estimated at the municipality level on the day of the event (lag 0) and two days earlier (lag 1 and lag 2) with those of control days from the same month, matched by temperature and accounting for day of the week (weekend vs week days). We applied conditional logistic regression models to obtain odds ratios (OR) and their 95% CI for an increase of 10 μg/m³ (PM₁₀) or 5 μg/m³ (PM_2.5) in pollutant concentrations over three lag days (lag 0, 1 and 2). We observed significant associations of PM₁₀ and PM_2.5 with treatment of acute thrombo-embolic events at the three lags. The strongest associations were observed for air pollution concentrations on the day of the event (lag0). Increases of 10 μg/m³ PM₁₀ and 5 μg/m³ PM_2.5 on lag0 increased the odds of events treated with endovascular intervention by 2.7% (95%CI:2.3%-3.2%) and 1.3% (95%CI:1%-1.5%), respectively, and they increased the odds of events treated with antithrombotic enzymes by 1.9% (95%CI:1.1-2.7%) and 1.2% (95%CI:0.7%-1.6%), respectively. The associations were generally stronger during autumn months and among children. Our nationwide study confirms that acute exposure to outdoor air pollutants such as PM₁₀ or PM_2.5 increase the use of medication and interventions to treat thrombo-embolic events.

Patch aortoplasty and anatomical lung resection in a patient with aortobronchial fistula due to aortic psuedo-aneurysm

Aortobronchial fistula (ABF) is a rare and devastating complication, if left untreated. Its main clinical manifestation is hemoptysis, and there are no defined guidelines for its treatment yet. Herein, we present the case of a 74-year-old male who complained of back pain and hemoptysis. The patient was diagnosed with pseudo-aneurysm and ABF, and he underwent hybrid thoracic endovascular aortic repair. However, hemoptysis recurred. With patch aortoplasty and anatomical lung resection, successful management of ABF was achieved, with no relapse for 5 years.